Urethritis in Men

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Urethritis and Urethral Discharge in Men article more useful, or one of our other health articles.

Description

Urethritis describes urethral inflammation and can be the result of infectious or non-infectious causes but is primarily a sexually acquired disease.

Urethritis can be diagnosed if any of the following are present:

Mucopurulent or purulent discharge from urethral meatus.

Gram stain of urethral smear showing >5 polymorphonuclear (PMN) cells per high power field. This is the preferred test as it is rapid, highly sensitive and specific for both nonspecific urethritis and gonorrhoea in asymptomatic men.[1]

First pass urine (FPU) positive for >10 PMN per high power field. Some advocate the use of positive leukocytes in FPU - but the sensitivity is low.

The most common organisms implicated are Chlamydia trachomatis and Mycoplasma genitalium. Chlamydia and M. genitalium are more likely to be detected in younger patients with NGU (although this association is not as strong for M. genitalium) and those presenting with a urethral discharge and/or dysuria.

The two organisms only infrequently co-exist in the same individual with NGU but dual infections have been identified in up to 10% of men in some studies.

Men with a urethral discharge have a higher bacterial load than those without.

In 30-80% of the cases with NGU neither C. trachomatis nor M. genitalium is detected. Pathogen-negative NGU is more likely with increasing age and the absence of discharge or clinical symptoms.

Trichomonas vaginalis is more common in non-white ethnic groups and appears to be uncommon in the UK. T. vaginalis isolation is greater in men aged over 30 years and may not always be associated with symptoms.

Ureaplasmas have been inconsistently associated with NGU. Earlier studies did not differentiate between two biovars: Ureaplasma urealyticum (biovar 2) and Ureaplasma parvum (biovar 1). There is increasing evidence that it is only U. urealyticum (biovar 2) which is pathogenic in some men at least but not U. parvum. U. urealyticum may account for 5-10% of cases of acute NGU.

A urinary tract infection may account for 6.4% of cases, although this is based upon the results of a single study.

Adenoviruses may account for perhaps 2-4% of symptomatic patients and are often associated with a conjunctivitis.

Epstein Barr virus, Neisseria meningitidis, Haemophilus spp., Candida spp., urethral stricture and foreign bodies have all been reported in a few cases and probably account for a small proportion of NGU.

The cause of organism-negative NGU (also called idiopathic urethritis) is unclear and has recently been reviewed. Some of these cases are almost certainly non-infective but the tools to be able to differentiate between infective and non-infective cases are not currently available.

Urethritis is the most common condition diagnosed and treated in men attending genitourinary medicine (GUM) clinics in the UK. Over 80,000 cases are diagnosed every year.

NGU is more common than gonococcal urethritis.

Chlamydia is most common in young people aged 15-24. It is the most common sexually transmitted disease in the UK. In 2009 there were 217,570 new cases diagnosed in any clinical setting. This was 7% more than in the previous year.

In 2013, the total number of new cases of gonorrhoea diagnosed in GUM clinics in England was 29,291. This was an increase of 15% compared to those diagnosed in 2012. The prevalence of gonorrhoea has increased gradually over a period of ten years, principally in men.

There was a disproportionate increase in men who have sex with men (MSM). In 2013, 63% of diagnoses of gonorrhoea occurred in MSM, a 26% increase on the previous year. This was thought to be due to a rise in men coming forward for testing as well as an increase in sexually unsafe activity.

The use of new diagnostic techniques - rectal and pharyngeal testing using nucleic acid amplification testing (NAAT) - has also improved detection rates.

The highest rates of gonorrhoea are amongst the young. In 2013 among heterosexuals diagnosed with gonorrhoea, 56% (8,122/14,647) occurred in those aged 15-24 years.

Presentation

May be asymptomatic (90-95% of men with gonorrhoea,[4]50% of patients with chlamydial infections).[5]

Urethral discharge - mucopurulent or purulent; with or without blood; more noticeable after holding urine overnight and more common in gonococcal infection.[6]May have gone unnoticed by the patient and be seen only on examination.[2]

Urethral pruritus, dysuria or penile discomfort with a risk of sexually transmitted infection (sexually active and has not used a condom or has a recent new sexual partner).[2]

Ideally this should be performed in a GUM clinic or primary care clinic which provides sexual health facilities as an enhanced service:

The diagnosis of urethritis is confirmed by demonstrating an excess of polymorphonuclear leukocytes in the anterior urethra. This is usually assessed using a urethral smear but a first-pass urine specimen can also be used.[1]Check with the local laboratory to see which investigations they provide.

FPU for NAAT is the best option to exclude chlamydia in men, as it is as accurate as, but less invasive than, a urethral swab. The sample should be collected at least one hour and preferably two hours after previous voiding.[9]

The local laboratory may be able to do NAAT on an FPU for gonorrhoea as well but, if not, a urethral smear will be required. Specimens should be sent to the laboratory as soon as possible. If there is likely to be considerable delay getting swabs from primary care to the laboratory, it may be preferable to ask the patient to attend a GUM clinic.

NAATs are the test of choice for testing asymptomatic individuals for urethral infection with N. gonorrhoeae.[4]

Pharyngeal and rectal swabs may also be needed.

A stick test of urine should be performed to exclude urinary tract infection.

General advice

Diagnose urethritis if there is urethral discharge present or if symptoms are in a high-risk patient.

Explain the likely causes.

Stress the importance of partner notification.

Explain the complications of inadequate treatment.

Emphasise the importance of abstaining from sex (including oral sex) for seven days after treatment (if azithromycin is used) or on completion (if doxycycline used) and until symptoms have resolved and partners have also completed treatment.

Empirical treatment - patients should be encouraged to attend a specialist service. However, in men who cannot or will not access such services, the opportunity should not be missed to provide treatment. Urethritis should be treated as early as possible and should be treated empirically as a presumed chlamydial infection, as this is the most common cause. Doxycycline 100 mg bd for seven days or azithromycin 1 g as single oral dose should thus be prescribed.

Stress to the patient that sexual intercourse should be avoided until the infection has cleared up and that partners should be checked out.

Contact tracing - it is important to maintain patient confidentiality. It is necessary to trace sexual contacts from the previous four weeks and up to six months if asymptomatic (for NGU). National guidelines on the management of gonorrhoea recommend that male patients with symptomatic urethral infection should notify all sexual partners within the preceding two weeks or their last partner if longer than two weeks.[5]

Patients should be followed up for review at approximately two weeks. Take this opportunity to reinforce health education. Assess compliance and efficacy.

Test of cure should be performed for gonorrhoea in all cases - eg, NAAT after seven days or repeat culture 72 hours after treatment has finished.[5]It is not routine for chlamydia unless the patient is pregnant, noncompliance is suspected or re-exposure may have occurred.[13]

Treatment failure

If symptoms persist or recur after treatment is completed, the man should be strongly advised to attend a genitourinary medicine (GUM) clinic or other local specialist sexual health service. If this is declined or not possible:

Check compliance with the initial drug treatment regime.

Exclude the possibility of re-infection. Check that current partner(s) have been treated appropriately and simultaneously.

Reconsider the diagnosis.

If the man has not adhered to treatment or has had sexual intercourse with an untreated partner, then re-treat (doxycyline 100 mg twice a day for 7 days or azithromycin 1 gram as a single dose) with appropriate partner notification.

If symptoms persist and the man has adhered to treatment and has not had sex with an untreated partner, consider prescribing azithromycin 500 mg dose once only, then 250 mg for the next 4 days, plus metronidazole 400–500 mg twice daily for 5 days.

If symptoms persist despite a second course of antibiotics then seek specialist advice.

Prognosis

If NGU, chlamydia and gonorrhoea remain untreated they may, rarely, remit spontaneously. However, this may take several months and carries the risk of transmission to others if the patient continues to have unprotected sexual intercourse.

Article Information

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